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ATI Funda

Practice Test A

Question	Answer
A Romberg test is standing with feet together with or without eyes closed to test stability
A Rinne test is used with a tuning fork to the side of the ear to indicate when they no longer hear the sound
Stroking the lateral side of the bottom of the client's foot to test for the presence of Babinski reflex
A pulse deficit occurs when there are differences between the radial and apical pulse rates. The nurse should have another nurse count the radial pulse as they count the apical pulse.
The nurse should delegate assisting a client to get out of bed because this task requires little technical skill or judgment and is within the AP's range of function.
The nurse should include objective and significant information about the client when documenting client data in the electronic health record.
The nurse should identify that rephrasing words and sentences may increase understanding of the teaching in a client who has a sensorineural hearing loss.
Repeating the same words or phrases will not increase the client's ability to hear the teaching.
An indication of malnutrition is Cachectic with flaccid muscle tone Skin is dry and scaly with bruises on extremities Abnormal pulse rate abdomen distended and BMI under 18.5
Irritated skin surrounding the stoma is an indication of inflammation or infection.
assign the client to a negative-pressure airflow room toa client with tuberculosis to ensure that the air from the client's room is not circulated throughout the facility.
If a patient is in pain but does not want pain medication the nurse should inquire why they do not want pain medication
tenderness and warmth in the client's calf, which can indicate the presence of a thrombus.
If thrombus moves from the vein to the heart, brain, or lungs, it can cause life-threatening complications.
Pink or red stomas indicate effective blood perfusion, which is crucial for the tissue's viability and healing.
check the pH of the gastric contents to verify tube placement.
place a rolled blanket or pillow along the outside of the client's affected leg to prevent external rotation of the hip.
Isometric exercises involve muscle contractions without any movement of the joints or changes in muscle length
Draining urine from the tubing before ambulation will prevent backflow of urine into the bladder preventing urinary tract infections
an occupational therapist assists the client with learning how to regain their ability to perform activities of daily living independently
A client who has dysphagia following a stroke should sit upright with their head tilted forward to facilitate swallowing and to prevent aspiration.
A picture board is a useful communication method for clients who have expressive aphasia because they are able to understand pictures.
Using the ABC priority framework, the nurse’s priority action is to assess the client’s respiratory status.
The greatest risk to the client in the post-operative period is airway obstruction
the nurse should use a 19-gauge soft Angio catheter to irrigate the wound, which provides the ideal pressure for cleaning secretions and exudate from the wound.
pneumonia, which is transmitted through droplets
Caffeine poses a risk, because it can lead to bone loss in patients with osteoporosis
As a diuretic, caffeine increases the excretion of calcium, and it may interfere with the absorption of Vitamin D.
providing postmortem care Validate the request for organ donation Collect specimens Remove all equipment, tubes, and indwelling lines Cleanse the body
the ventrogluteal site because this is the preferred site of IM injections for adults.

Created by: Daarina Jones

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